Báo cáo y học: "Association between regulated upon activation, normal T cells expressed and secreted (RANTES) -28C/G polymorphism and asthma risk – A Meta-Analysis"
Int. J. Med. Sci. 2010, 7 http://www.medsci.org 55IInntteerrnnaattiioonnaall JJoouurrnnaall ooff MMeeddiiccaall SScciieenncceess 2010; 7(1):55-61 © Ivyspring International Publisher. All rights reserved Research Paper Association between regulated upon activation, normal T cells expressed and secreted (RANTES) -28C/G polymorphism and asthma risk – A Meta-Analysis Qiaoqiao Fang 1*, Furu Wang 2*, Deyu Zhao1 1. Department of Respiratory Medicine, Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing 210029, China; 2. Department of Epidemiology and Biostatistics, Cancer Center, Nanjing Medical University, Nanjing 210029, China * Contributed equally. Corresponding author: Dr. Deyu Zhao, Department of Respiratory Medicine, Nanjing Children’s Hospital Affiliated to Nanjing Medical University, 72 GuangZhou Rd, Nanjing 210029, China. Tel (Fax): 86-25- 831-17367. E-mail: zhaodeyu98@126.com Received: 2010.01.15; Accepted: 2010.02.04; Published: 2010.02.10 Abstract Regulated upon activation, normal T-cell expressed and secreted (RANTES) is one of the most extensively studied C-C chemokines in allergic inflammation. A growing body of evi-dence suggests that many cell types present in asthmatic airways have the capacity to gen-erate RANTES, which directly supported the potential role of RANTES in asthma. A number of studies have evaluated the functional polymorphism -28C/G in the RANTES promoter re-gion, which had been found to affect the transcription of the RANTES gene, in relation to asthma susceptibility. However, the results remain conflicting rather than conclusive. This meta-analysis on 1894 asthma cases and 1766 controls for -28C/G from 9 published case-control studies showed that the variant allele -28G was associated with significantly increased risk of asthma (GG+CG vs CC: OR=1.24, 95%CI=1.08-1.41) without any be-tween-study heterogeneity. In the stratified analysis by asthma type, age and ethnicity, we found that the increased asthma risk associated with -28G/C polymorphism was more evident in children (OR=1.24, 95%CI=1.06-1.45), Asian group (OR=1.27, 95%CI=1.04-1.56) and African group (OR=1.72, 95%CI=1.07-2.78). These results suggest that RANTES -28G/C polymorphism may contrib-ute to asthma development, especially in children and in Asian population. Additional well-designed large studies were required for the validation of this association. Key words: RANTES, polymorphism, susceptibility, asthma, meta-analysis Introduction Asthma is a chronic inflammatory disorder of the airways and is characterized by variable airflow obstruction and bronchial hyper responsiveness (BHR) [1]. The prevalence and severity of asthma have been increasing in many countries, the trends being most pronounced for children and adolescents [2]. The pathogenesis and etiology of asthma is very complex and not fully understood, although an in-teraction of multiple genetic loci and a variety of en-vironmental factors have been suggested as impor-tant determinants of this disease [3,4]. It was reported that asthma is a disease with a strong genetic predis-position, and the recent increase in asthma cases seems to be triggered by increases in environmental Int. J. Med. Sci. 2010, 7 http://www.medsci.org 56exposures in previously unaffected but genetically susceptible individuals [5]. However, different ge-netic background individuals in the same environ-mental exposures showed different susceptibility to asthma, which indicated that genetic factors may play an important role in the pathogenesis of asthma. Regulated upon activation, normal T-cell ex-pressed and secreted (RANTES), which generated by T lymphocyte, is one of the most extensively studied C-C chemokines in allergic inflammation[6]. RANTES is likely to be important in airway inflammation be-cause blocking antibodies to RANTES inhibit airway inflammation in a murine model of allergic airway disease [7]. A growing body of evidence suggests that many cell types present in asthmatic airways, such as T cells, platelets, macrophages, endothelial cells, fi-broblasts, epithelial cells, and mast cells, have the ca-pacity to generate RANTES [8], which directly sup-ported the potential role of RANTES in asthma. The gene encoding RANTES is located on chro-mosome 17q11.2-q12 [9] that has been shown to be in linkage with asthma in several studies [10,11]. The -28C/G polymorphism in the RANTES promoter re-gion had been found to affect the transcription of the RANTES gene. In human cell lines, the -28G was shown to increase promoter activity of RANTES in comparison with the more frequent -28C, suggesting that the polymorphism can increase RANTES expres-sion in the human body [12]. Therefore, it’s reason-able to hypothesize that the RANTES -28C/G poly-morphism may functionally relate to the risk of asthma. A number of molecular epidemiological studies have been conducted to examine the association be-tween RANTES -28C/G polymorphism and asthma susceptibility [1,13-20], but the results remain incon-sistent. To estimate the overall risk of RANTES -28C/G associated with asthma risk and to quantify the potential between-study heterogeneity, we con-ducted a meta-analysis on 9 published case-control studies with 1894 asthma cases and 1766 controls for -28C/G. Materials and Methods Identification and Eligibility of Relevant Studies. Eligible studies were identified by searching the electronic literature PubMed and EMBASE for relevant reports (last search update February 2009, using the search terms “RANTES”, “polymorphisms” and “asthma”; “CCL5”, “polymorphisms” and “asthma”). Additional studies were identified by hands-on searches from references of original studies or review articles on this topic. Searching was per-formed in duplicate by two independent reviewers (Q.F. and F.W.). Results were limited to English lan-guage papers and Chinese language papers. Inclusion criteria. We attempted to include all the case-control studies published to date on the as-sociation between RANTES -28C/G polymorphism and asthma risk. Human studies, regardless of sam-ple size, were included if they met the following cri-teria: (1) RANTES polymorphism at -28C/G were de-termined. (2) Studies were case-control design (retrospec-tive or nested case-control). (3) Each genotype frequency was reported, and there was sufficient information for extraction of data. (4) If studies had partly overlapped subjects, only the one with a larger and/or latest sample size was selected for the analysis. Data Extraction. Two reviewers (Q.F. and F.W.) independently extracted data and reached a consen-sus on all of the items. Data extracted from these arti-cles included the first author’s name, year of publica-tion, country of origin, ethnicity, type of asthma, number of cases and controls, and the minor allele fre-quency in controls. Meta-Analysis. The risk of asthma associated with -28C/G RANTES was estimated for each study by odds ratio (OR) with 95% confidence intervals (95%CI). For all studies, we evaluated the risk of the variant genotypes (GG/CG), compared with the wild-type genotype (CC). Then we calculated the ORs of the polymorphism (GG+CG versus CC, and GG versus CG+CC), using both dominant and recessive genetic models of the variant G allele. In addition, we conducted stratification analysis by asthma types, age and ethnicity. As a result, 2 case-control studies of asthma type (777 cases and 495 controls); 9 case-control studies of age (1894 cases and 1766 con-trols) and 9 case-control studies of ethnicity (1894 cases and 1766 controls) were available for this meta-analysis. The χ2-based Q statistic test was used for the assessment of heterogeneity, and it was con-sidered significant for P < 0.01. We used the fixed-effects model and the random-effects model based on the Mantel-Haenszel method and the Der-Simonian and Laird method, respectively, to combine values from each of the studies. When the effects were assumed to be homogenous, the fixed-effects model was then used; otherwise, the random-effects model was more appropriate. We also computed the power of the selected studies by using the DSTPLAN4.2 software, in order to assess the prob-ability of detecting an association between RANTES -28C/G polymorphism and asthma at the 0.05 level of Int. J. Med. Sci. 2010, 7 http://www.medsci.org 57significance, assuming a genotypic risk of 2.0 and 1.5. The Egger’s test and inverted funnel plots were util-ized to provide diagnosis of publication bias (Linear regression analysis, ref. [21]). All analysis was done by using the Statistical Analysis System software (v.9.1.3, SAS Institute, Cary, NC) and Review Manage (v.4.2). All the P values were two-sided. Results The selected study characteristics are listed in Table 1. All studies indicated that the distributions of the -28C/G polymorphism’s genotypes in the con-trols were both consistent with Hardy-Weinberg equilibrium except for two studies [18,19]. The minor G allele frequency (MAF) was 0.14 for Asian studies, 0.06 for African, while around 0.03 for Caucasian, respectively. Variant genotypes of RANTES -28C/G poly-morphisms were associated with an increased asthma risk in different genetic models. As shown in Table 2, both the variant homozygote (-28GG) and heterozy-gote (-28CG) were associated with a significantly in-creased risk of asthma (GG versus CC: OR=1.98, 95%CI=1.24-3.16; P = 0.29 for heterogeneity test; CG versus CC: OR=1.25, 95%CI=1.04-1.50; P = 0.60 for heterogeneity test), compared with wild-type homo-zygote (-28CC). Significant main effects were also observed in the dominant genetic model (GG+CG versus CC: OR=1.24, 95%CI=1.08-1.41; P = 0.47 for heterogeneity test; Table 2 and Figure 1). We further performed stratified analysis ac-cording to asthma type (atopic asthma and non-atopic asthma), age (children and adult) and eth-nicity (Asian and Caucasian and African ethnicity), and the estimate results were presented in Table 3. As shown in the table, we found that the increased asthma risk associated with -28G/C polymorphism was more evident in children (OR=1.24, 95%CI=1.06-1.45, P=0.39 for heterogeneity test), Asian group (OR=1.27, 95%CI=1.04-1.56, P=0.48 for hetero-geneity test) and African group (OR=1.72, 95%CI=1.07-2.78, P=0.23 for heterogeneity test). We used Funnel plot and Egger’s test to access the publication bias of literatures. As shown in Fig. 2, the shape of the funnel plots seemed symmetrical in the dominant genetic model for the -28C/G, suggest-ing that there was no publication bias. Egger’s test was used to provide statistical evidence. As a result, no publication bias was observed for -28C/G (t=2.30, P = 0.92). Table 1. Characteristics of published studies included in the meta-analysis. Power (%) † Author[ref*) Year Origin (Ethnicity) Asthma group (CC/CG/GG) Control group (CC/CG/GG) HWE MAF in controls OR>1.5 OR>2.0 Szalai C[13]& 2001 Hungary ( Caucasian) 144/16/0 284/19/0 0.573 0.03 11.9 29.7 Hizawa N[14] 2002 Japan ( Asian) 216/70/12 243/62/6 0.387 0.12 41.7 88.2 Yao TC[15] 2003 China(Taiwan) ( Asian) 134/39/9 83/23/1 0.666 0.12 21.3 55.3 Wang LJ[16] 2004 China ( Asian) 65/31/4 72/17/1 0.998 0.11 15.5 39.7 Huang JL [17] 2005 China(Taiwan) ( Asian) 189/53/9 83/23/1 0.666 0.12 23.3 59.8 Moissidis I[18] 2005 United States ( African-American) 59/2/0 129/0/0 0.000 0.00 NA# NA# Lachheb J[19] 2007 Tunisia ( African) 163/35/12 190/29/5 0.005 0.09 25.8 65.9 Muro M[20] 2008 Spain (Caucasian) 289/17/0 228/14/0 0.643 0.03 14.1 36.7 Sohn MH[1] 2008 Korea ( Asian) 218/93/15 174/66/13 0.050 0.19 52.1 94.6 * The ref was referred to the reference numbers in this study. & data from the same source, so selected by the latest sample size. # NA: Not available. † Power was calculated by the DSTPLAN4.2 software with MAF in controls as the frequency of risk factor, OR was selected 1.5 and 2.0 as the relative risk and а=0.05 as the significance. Int. J. Med. Sci. 2010, 7 http://www.medsci.org 58Table 2. Summary ORs of the RANTES -28C/G polymorphism and asthma risk. Comparison No. of Cases No. of Controls OR 95%CI P* CG vs CC 1833 1739 1.25 1.04-1.50 0.60 GG vs CC 1538 1513 1.98 1.24-3.16 0.29 GG vs CG+CC 1894 1766 1.88 1.18-3.00 0.30 CG+GG vs CC 1894 1766 1.24 1.08-1.41 0.47 * Test for heterogeneity. Fixed-effects model was used when P value for heterogeneity test > 0. 01; otherwise, random-effects model was used. Table 3. Association between asthma risk and the RANTES -28C/G polymorphisms, stratified by asthma type, age and ethnicity. Stratified variable Studies of available$ No. of Cases No. of Controls OR# 95%CI P* asthma type atopic [1,20] 577 495 1.04 0.75-1.44 0.81 non-atopic [1,20] 200 495 1.15 0.69-1.90 0.61 age children [1,13,15-17,19] 1229 1084 1.24 1.06-1.45 0.39 adult [14,18,20] 665 682 1.24 0.96-1.60 0.29 ethnicity Asian [1,14-17] 1157 868 1.27 1.04-1.56 0.48 Caucasian [13,20] 466 545 1.27 0.77-2.11 0.22 African [18,19] 271 353 1.72 1.07-2.78 0.23 # The OR was obtained in dominant genetic model. * Test for heterogeneity. Fixed-effects model was used when P value for heterogeneity test > 0.10; otherwise, random-effects model was used. $ Studies of available was referred to the reference resource of each stratified variable, which data was available. Figure 1. ORs (log scale) of asthma associated with RANTES -28C/G for the CG+GG genotypes, compared with the CC genotype. Int. J. Med. Sci. 2010, 7 http://www.medsci.org 59 Figure 2. Funnel plot analysis to detect publication bias in asthma. Each point represents a separate study for the indicated association. For each study, the OR is plotted on a logarithmic scale against the precision (the reciprocal of the SE). Discussion Regulated upon activation, normal T-cell ex-pressed and secreted (RANTES) is a C-C chemokine that has been shown to be a potent chemoattractant for T cells, eosinophils, basophils, mono-cyte/macrophages, and mast cells [22]. It has been shown that RANTES induces recruitment of eosino-phils and their up regulation into the airways of asthmatic patients causing tissue damage [23-25]. Both atopic asthma and nonatopic asthma are associ-ated with increased levels of RANTES in bronchoal-veolar lavage fluid [26] and bronchial mucosal ex-pression of RANTES (together with eosinophil-active cytokines such as interleukin-5, granulocyte macro-phage colony-stimulating factor, and interleukin-3), which contributes to the bronchial mucosal accumu-lation of activated eosinophils [27]. Mutations in the proximal promoter region of the RANTES gene may affect transcriptional activity and sub-sequently RANTES over expression in lung cells [19]. It was re-ported that over expression of RANTES causes in-creased neutrophils and eosinophils infiltration into the airways, which are considered a prominent fea-ture of airway inflammation [28]. This inflammation is resulting mainly from recruitment of eosinophils in a manner that correlates with asthma severity [29]. Therefore, as one of the C-C chemokines, the RANTES polymorphisms necessarily resulted into the level of eosinophils elevating correspond, and then increased the individual risk of suffering from asthma. The expression of RANTES is differentially regulated in various cell types, and a large number of putative cis-acting elements have been described in the promoter region by Nelson et al. [6], who subse-quently also identified a novel regulatory region critical for its expression [30]. The RANTES -28C/G polymorphism was found to be adjacent to the NF-кB binding site, which is a potent inducer of RANTES expression [31]. It has also been reported that the -28G allele elevates promoter activity and increase RANTES protein expression in the functional study [12]. In addition, Hizawa et al. [14] suggested that mononuclear cells from subjects who carried the -28G allele produced significantly greater levels of RANTES protein than cells from subjects who did not carry this allele. Thus, it is reasonable to hypothesize that the -28C/G polymorphism with higher activity of RANTES may play more important role in asthma risk. In the present meta-analysis on the association between RANTES -28C/G polymorphism and risk of asthma, we found that the variant -28G alleles could significantly increase the risk of asthma, which is consistent with the hypothesis from previous studies that the -28C/G polymorphism with higher activity of RANTES may be more important in asthma risk, although the association was not significantly evident in most studies individually. In addition, in stratified analysis, we observed that the association between -28C/G and risk of asthma was remained significant in Asian and African population. The different effect of ethnicity may result from several reasons such as: less numbers of available studies for stratified vari-able, which may result into poor statistic power; dif-ferent genetic background and environmental expo-sures, which may contribute to ethnic difference. In addition, it is worth emphasizing that the -28C/G polymorphism was contributed to the increase of asthma susceptibility in children, which may helpful to understand the pathogenesis of children's asthma. Furthermore, small numbers of individuals and in-consistent stratification standards in environmental exposures and genotypes by the published studies limited our statistic power to fully investigate the gene-environment interaction. In spite of this, our meta-analysis shares some Int. J. Med. Sci. 2010, 7 http://www.medsci.org 60key advantages in several aspects. First, substantial number of cases and controls were pooled from dif-ferent studies, which significantly increased statistical power of the analysis than each individual study. Second, the quality of case–control studies included in current meta-analysis was good and met our inclu-sion criterion. Third, we did not detect any publica-tion bias indicating that the whole pooled result should be unbiased. In conclusion, this meta-analysis of 9 case-control studies provided evidence that the RANTES -28C/G polymorphism was significantly associated with increased risk of asthma, especially in children. Further well-designed large studies, par-ticularly referring to gene-gene and gene-environment interactions are warranted to con-firm the real contribution of RANTES -28C/G poly-morphism to asthma susceptibility. Acknowledgement This work was supported in part by Nanjing Medical scientific and technological develop-ment-funded projects (ZKX0306). Conflict of Interest The authors have declared that no conflict of in-terest exists. References 1. Sohn MH, Kim SH, Kim KW, et al. Rantes gene promoter polymorphisms are associated with bronchial hyperresponsiveness in korean children with asthma. Lung. 2008; 186: 37-43. 2. Weiss ST. Epidemiology and heterogeneity of asthma. Ann Allergy Asthma Immunol. 2001; 87: 5-8. 3. Sengler C, Lau S, Wahn U, et al. 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